IntraPet Ultrasound Patient Information Form

IntraPet Patient Information
To schedule:

TEXT: 410-849-6867 or

EMAIL: intrapetstaff@gmail

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DATE OF ULTRASOUND APPOINTMENT: CONFIRMED appointment indicates Hospital has agreed to pay Ultrasound exam fee or cancellation fees if applicable.

MonthDayYear
Confirmed with IntraPet and Owner
REQUESTED DATES for ultrasound (if not already confirmed with IntraPet, format: month/day). Any notes re appt may be added here
Hospital Name (No acronyms or #’s)*
DVM Name
Pet Name*
Owner Last Name *
Date of Birth*

MonthDayYear
Date
Weight (specify lbs or kg)*
Over 95# may incur additional fees, please inquire at time of scheduling
Species/Breed*
Sex*
Ultrasound Exam-select all that apply. (Abdominal includes urinary & repro)*

AbdominalEchocardiogram (Heart function)Specialty-Chest, Urinary, Thyr, PregProcedure-FNA, Centesis, OTHERECG 6 lead
If Specialty or Procedure specify type:
(Urinary, Thyroid, Chest, Pregnancy, FNA)
Previous IntraPet Ultrasound?*
Date of Previous IntraPet Ultrasound
PLEASE SPECIFY ECHO OR ABD
If concern for second cavity pathology is seen during a scan (ex: splenic mass, pleural effus, enlarged abd vess), a LIMITED screening for pericardial effusion or heart based mass only is approved for $40*
Presenting Complaint/History/PE*
GRADE OF MURMUR REQUIRED IF ECHOCARDIOGRAM
Tentative diagnosis/ Questions to be answered with ultrasound*
Brief abnormalities for Lab Results/Radiograph Findings (please upload full results or email intrapetstaff@gmail)
*INCLUSION OF ENTIRE MEDICAL CHARTS/VISIT NOTES ETC WILL RESULT IN ADDITIONAL FEES.
Medications with dosage and duration
Sedation is NOT a requirement, it is recommended with some patients to achieve a diagnostic ultrasound, but it is ultimately the decision of DVM and the owner. *Certain sedatives interfere with echocardiograms, please contact us with any questions scan or injection.
Sedation— any instructions can be listed in box below*

YES, IV sedation is approved IF deemed necessary during the ultrasound. We use sedation if we cannot accomplish a diagnostic scan without it.YES, Intramuscular sedation — The hospital agrees to pay a fee if sedation is not administered at IntraPet arrival, I agree to enter contact info below.NO, sedation is declined. If sedation choice is "NO", this indicates DVM/owner have declined sedation. IntraPet will not ask for sedation at the time of the scan if "NO" is selected, even if patient condition does not allow for a full diagnostic scan. Ultsound exam fee still applies.
Sedation: please type dosages (or “in medical chart”) and any information regarding sedation.
SEDATION DOSES MUST BE AVAILABLE AT THE TIME OF THE SCAN HERE OR IN MEDICAL RECORD
For approximate eta window: WE WILL NOT CALL A VOICE CALL NUMBER, please enter a TEXT or EMAIL ONLY. The sonographer will notify staff when they enter the hospital. This eta window is not guaranteed. Add-ons, cancellations and traffic affect our eta. Intramuscular sedation must have contact info entered here.
*PATIENT MUST HAVE BEEN DROPPED OFF IN HOSPITAL BEFORE 8 AM.
PLEASE NOTE: All patients must be dropped off by 745 am unless prior arrangements have been made at the time of scheduling.

Please inquire about for non-drop off scans if you have special circumstances, additional fees are charged for any patients that have not been dropped off in am.

Thank you!!
Confidential questions/concerns, information for specialist/sonographer. WILL NOT APPEAR ON FINAL REPORT
Lab work / Rads

Cancelof
Yes, employee pet No, not employee pet* Employee name matches patient name.
Same day report is approved if emergency and patient is in critical condition. (Same day reports are 2-6 hours after the scan has been completed)*

YES, approved. Sonographer must be told to submit prior to leaving the hospital.NO, not approved.PLEASE SUBMIT FOR SAME DAY REPORT REGARDLESS OF FINDINGS
Please enter your Email to receive a PDF copy of this form for your records. Your form will be editable from the link you receive at this email.*
example@example.com
Secondary email if above email is not clinic email.
example@example.com
I have contacted IntraPet by text or separate email to schedule this exam:*

YES, I have contacted IntraPet.NO, I have not contacted IntraPet and will do so after this form submission.
TEXT/CALL 410-849-6867 or EMAIL intrapetstaff@gmail

THANK YOU!
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IntraPet Patient Information